ATIVIDADE LÚDICA COMO FERRAMENTA PARA O CUIDADO DE ENFERMAGEM ÀS CRIANÇAS HOSPITALIZADAS PLAY AS A TOOL IN NURSING CARE FOR HOSPITALIZED CHILDREN LA ACTIVIDAD LÚDICA COMO HERRAMIENTA DE ENFERMERÍA PARA EL CUIDADO DE NIÑOS HOSPITALIZADOS

The study aims at synthesizing existing knowledge about play as a tool in nursing care for hospitalized children. It is an integrative review carried out at Scopus, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane and Latin American and Caribbean Health Sciences (LILACS) databases. Among the thirteen reviewed studies, 46% used randomised clinical trial; doll therapy was most commonly used (46%), followed by toys (30%). As for the benefits of play for children, we observed improvement in negative symptoms such as pain, nausea, anxiety and depression, as well as in the relationship between the nursing staff and the child. Results showed that scientific production on the theme is incipient. The researchers stress that health benefits are closely related to the type of activity carried out; however, it is necessary to emphasize that nurses should be aware of the benefits of this type of therapy to better organize their working process.


INTRODUCTION
Hospitalization disrupts daily routine of children and their families; it affects their living and being process. A hospitalized child may express momentary dissatisfaction; have developmental regression or slowdown, sleep and nutrition disorders, addiction, aggression, apathy, depressive states, phobias, anxiety, insecurity, fear and behavioural disorders in general. 1 Given children's fanciful and egocentric elaborations, they may consider illness and/or hospitalization as a punishment for misbehaviour. In this sense, play is a means through which children can understand their condition, acquire knowledge, and discover their individuality to better cope with their current condition. 2 In a hospital setting, play can change the ward into a pleasant place to which the child can adapt more easily. 2 Furthermore, it nurtures children's moments of reasoning, discovery, persistence and perseverance through which they can cultivate patience and persistence in the face of adversity. Therefore, toys can be used to recreate, stimulate, and socialize, in addition to fulfil their therapeutic function. 3 Toy therapy allows the minimization of child anxiety and distress caused by experiences considered atypical at an early age. It is indicated whenever the child has difficulty understanding, does not know how to react to a difficult experience or requires preparation for invasive and/or painful procedures. 1 Play therapy is a facilitating resource in nursing interventions. However, little or no importance is given to these children´s social and psychological aspects, as their physiological needs demand more attention.
The nursing staff should recognize the benefits afforded by playing and provide the means for its implementation, incorporating it systematically in their care routine. 4 Play is, therefore, a therapeutic tool to promote continuous child development. It also helps children understand the difficult time they are going through. Thereby, the present research raises the following questions: what kind of play do nurses use with hospitalized children? What are the benefits of these activities? What is the impact of the incorporation of play into nursing care? This study aims hence at synthesizing scientific production on play as a nursing care tool for hospitalized children.

METHODOLOGY
The present study is an integrative review, a method that gathers and synthesizes research findings on a defined topic. It aims at expanding and integrating knowledge and possible applicability to practices. 5,6 Search strategies were defined by a research protocol that guided the study. The integrative review included the following stages: definition of themes and guiding questions; criteria for study selection; data definition and study categorization; study assessment; interpretation of results and review presentation. 6 The studies were selected in May 2013. The consulted databases were Scopus, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane and Latin American and Caribbean Literature on Health Sciences (LI-LACS). The controlled descriptors listed by the Health Sciences (DeCS) were criança hospitalizada, atividades lúdicas and enfermagem, and their equivalents in Mesh: hospitalized child, play therapy and nursing. The descriptors were crossed in the same order using operators "e" and/or "and".
The selected studies met the following inclusion criteria: scientific articles dealing with at least one of the guiding questions; written in Portuguese, Spanish or English, full text available and free of charge in the selected databases. The researchers decided to exclude edicts, letters to editors and expert opinions. The period of publication was not taken into account in order to identify as many articles as possible.
Silveira Mendes and Galvão's proposal 6 was used for the critical evaluation of the studies. Such proposal consisted of an instrument to synthesize relevant information. The paper´s year of publication, study design, level of evidence, 7 type of play, benefits of the activity to the child and how such activities might influence the nursing process were all identified and analysed.
The final sample consisted of thirteen articles, nine of them in scopus, two in CINAHL, one in LILACS and one in Pubmed. It is worth mentioning that one article appeared both in LILACS and Scopus and six studies were found in Cochrane, none of them, however, available for free in full-text.

RESULTS
Out of those 13 studies two (15%) were published between 1989 and 1999, five (39%) between 2004 and 2008 and six (46%) between 2008 and 2011. One study (7%) was carried out in Great Britain and two (15%) in the United States. Brazil and China published five (39%) studies each.
As for the method employed, six (46%) articles used randomized clinical trial; five were qualitative descriptive studies (39%); and non-randomized clinical trial and mixed methods one research each (7%). A total of six studies comprised a sample whose results presented level 6 Evidence, as seen in Table 1.
Doll therapy was the most commonly used type of activity, with six (46%) studies, followed by toys therapy, with four (30%) studies. The benefits of play for children are briefly listed in Table 2.
Only three (23%) articles dealt with the impact of play on the nursing work process. They reported that when such therapy is considered part of nursing care in paediatric inpatient units it does not take up much of the nursing staff´s time and neither hinders their performance. 16

Play activities carried out by the nurse
Care for the hospitalized child should strive to mitigate traumas arising from its stay in hospital. In this context, when play therapy is carried out the hospital environment can be tailored to the child´s needs. 3 Such activities may include several strategies which usually involve play, essential to the interaction between child and environment.
Clowning involves professionals who assume the characters and identities they create. They normally wear clown nose, carry tambourines, colourful stethoscopes and briefcases and use music, storytelling, magic tricks and dramatization. Nurses may choose specific days of the week for such activities. A study using this technique said professionals had agreed on twice a week and that this therapy was now part of the hospital routine. 8 The art of clown theatre in care for hospitalized children 8 Lima, Azevedo, Nascimento and Rocha Qualitative descriptive level 6 The effect of play on immobilized children in hospital 9 Gillis AJ Randomized clinical trial level 2 Reading as a method of humanized care in the pediatric neurological clinic: A qualitative study 10 Silva Understanding nurses' awareness as to the use of therapeutic play in child care 20 Maia, Ribeiro and Borba Qualitative (symbolic interactionism) level 6 * Studies using same clinical study. Source: research data. Reading groups and storytelling, mentioned in two studies 8,10 , are excellent tools for the development of several aspects of child psychology (imagination, reasoning, creativity, etc. ). They transmit values (ethics, love, respect, peace, cooperation, etc. ), promote culture and disseminate information. 10 According to the studies, they can be done individually or in groups and without a professional. They should be carried out in quiet and cosy places such as toy libraries.
Another activity used by nurses is creative art therapy (CAT). It involves three techniques: music therapy, dance/movement therapy and art therapy through drawings. It comprises six sessions, two sessions for each technique. It is worth mentioning that in the research using this activity a professional dancer was hired to instruct the dance/movement stage of the experience. 18 The interactive virtual playground is a new type of play that uses a computer program -PlayMotion® -to create virtual environments such as beaches, parks and sports fields. Projected images of a virtual environment transform ordinary walls, floors and ceilings into interactive virtual playgrounds. Children have to change attitudes according to what is being presented. 17 It can be an individual activity; however, the best benefits are observed when it is performed in groups of four children, five days a week, during 30 minutes. 17 In this context, it is important to emphasize that this type of play is not recommended to all: children undergoing aggressive treatment and with severe condition need medical and nursing evaluation.
To play alone or in group is another strategy used by nurses to encourage children to play freely, using toys, play dough, old magazine pictures and puppets, among others. 13,19,20 It is a recreational activity that does not need the presence of a professional. Time and place are set by the professional responsible for it; however, we observed that such strategy is usually performed during toy library sessions.
On the other hand, although all these activities are somehow performed, children should be told about what is going to happen to them for them not to feel so uncomfortable at hospital. In this context, the nurse is an educator expected to use creative techniques to meet the needs of the public. 21 In response to those specific demands, nurses have been using doll therapy simulating procedures the child will be exposed to. 11,12,[14][15][16]19 The child itself may also simulate the procedures in the doll, as observed in a study carried out in Hong Kong. 14 Therefore, it is up to the professional to decide when to use this technique.

Benefits of play ther apy to the child
The literature on the subject acknowledges the importance of play and recommends it as part of paediatric nursing care. It helps hospitalized children to cope with the pain and stress generated by the experience. 22 Considering that the child needs more attention and care and that disruptions interfere with its quality of life and full development, the use of play therapy can contribute to minimizing the stressful effects of hospitalization and provide more humanized care. 3 These studies demonstrate that the use of play reduces negative feelings and pain complaints, nausea, anxiety and depressive feelings, and also helps communication between nurses and children. Furthermore, the results reveal better adherence to treatment and physical, mental, emotional and social development. 12,14,15,17 Playing makes hospitalization less traumatic and stimulates the child's normal development, enabling its physical and emotional recovery. Moreover, it can reduce tensions, anger, frustration, conflicts and anxiety, creating helpful ties between children and nurses. 3 Thus, play therapy for hospitalized children is a therapeutic tool to promote continuous child development and physical and emotional restoration. It also makes the hospitalization process less traumatic and provides better conditions for recovery.

Influence of play on the nursing work process
Nursing has always linked provision of care with art, which is the essence of the profession. It seeks to offer dignity and quality of life through comprehensive and humanized care. 21 Health professionals consider children to be a differentiated public that requires interventions adapted to different age groups. Play therapy aims therefore at giving dynamism to care and at integrating it into the hospital setting, which is not an easy task. 21 A rather small number of studies demonstrated the influence of play on the nursing work process and if such influence is negative or not. A study dealing with doll therapy 16 demonstrated that the activity is easily performed and incorporated into the nursing care routine, with the proviso that its use is planned.
According to a research assessing the use of toys 19 , such therapy can be systematically incorporated into clinical practice without inconveniencing the nursing care process. Study on activities on a computer also stressed that they do not require more of the nurse's time. It highlights however that play will only be systematically used by such professionals if they consider that it is part of a holistic approach to nursing care aiming at lessening psychological distress. 17 Many studies discuss play and its benefits to the child; however, little has been said about how to use it and what the difficulties are. Thus, we believe that these practices will be best incorporated when more research addressing the issues are carried out.